Paediatric Primary Survey (the rough guide).

It is always a good idea to develop your own systematic way of performing a quick and structured evaluation (and documentation) of every paediatric patient under your care.
Here is one such approach,  a rough guide to performing a paediatric primary survey taken from notes I made during an advanced paediatric life support course ( and if you are in Australasia and looking for an excellent one….here is my recommendation: APLS ).

Airway & Breathing: Look, Listen, Feel.

EFFORT:

Tachypnoea at rest indicates need for increased ventilation.

• Lung or airway disease OR
• Metabolic acidosis

Bradypnoea at rest:

• Fatigue
• Cerebral depression
• Pre-terminal state

Recession:
Intercostal, sub-costal, sternal = increased effort of breathing. More easily seen in infants as they have a more compliant chest wall.
Remember: Recession decreases as exhaustion increases.

Insp/exp noises:

Stridor = laryngeal or tracheal obstruction (insp usually > exp)
Wheezing = lower airway narrowing (usually greater during expiration)
Grunting = exhalation against partially closed glottis (sign of severe respiratory distress!) Characteristically seen in pneumonia & pulmonary oedema.
May also be seen in raised ICP.

Accessory muscle usage: sternomastoid (muscles in anterior part of neck). In infants this results in an appearance of head bobbing.
Flaring of the Alae Nasi.
Gasping = severe hypoxia. Pre-terminal sign.

3 EXCEPTIONS where you may not see increased effort of breathing in unwell child:

• Patients with chronic severe respiratory problems.
• Cerebral depression from raised ICP, OR poisoning, OR encephalopathy.
• Patients with neuromuscular disease (eg Spinal muscular atrophy, muscular dystrophy).

EFFICACY:

Search for:

Chest expansion in child.
Abdominal excursion in infant.
Auscultation: Listen for

• Reduced air entry.
• Asymmetrical air entry.
• Bronchial breath sounds.

Note to self: Don’t get all arty when quickly auscultating the chest. Place stethoscope over anterior chest wall (mid-clavicular line) and compare with other side. Then auscultate under both axilla. Done.

SaO2: Less accurate when < 70%, OR shock, OR carboxyhaemaglobin.

EFFECT: (on other organs)
Heart rate: Hypoxia produces tachycardia in older infant in child (as does anxiety).
Severe or prolonged hypoxia may lead to bradycardia.
Skin Colour:

• catecholamine release = vasoconstriction.
• Cyanosis is a LATE sign.
• Central cyanosis = impending respiratory arrest!
• Note: anaemia may mask cyanosis.
• Patients with congenital heart disease may remain cyanotic despite O2.

Mental Status: Note if agitated or drowsy.

Circulation:

Heart rate: increased in shock due to catecholamine release + decreased stroke volume (SV).
(Infants have small, fixed SV therefore to increase cardiac output they need to increase heart rate).
Pulse Volume: Good indication of perfusion: compare central and peripheral pulses.
Weak central + absent peripheral = advanced shock.
Bounding pulses = high cardiac output (eg septic shock)

Cap Refill: Press on sternum for 5 sec.
Normal = 2–3 sec cap refill.
Note: Poor skin perfusion or low ambient temp reduces reliability.

Blood Pressure:
Normal: 80+(age x 2).
Note: changes in BP are a late sign.
Correct cuff size is important: >80% of length of upper arm.

Effects (on other organs):
Respiratory: Increased resp rate with increased tidal volume but no recession = metabolic acidosis.

Skin: Look for mottled / Cool.

Urine output: At least
1m/kg/hr for children.
2ml/kg/hr for infants.

Neurological:

Level of consciousness:
Initially, use AVPU (Alert | Voice | Pain | Unresponsive).
P or U = GCS of 8 or less.
Posture: seriously ill are usually hypotonic.
Pupils: check for size, reactivity and equality.

Finally: Don’t ever forget glucose! (Consider need for cap BSL).